Questions about Medicare and private insurance?
A pelvic health issue can be stressful enough without insurance complications and coverage concerns. Take a moment to browse a few of our most frequently asked questions to find some of the answers you need.
Does Medicare cover procedures that utilize American Medical Systems (AMS) products?
Medicare generally covers procedures that use AMS products when the patient meets medical necessity. Medicare has specific National Coverage Determinations (NCD) for two specific conditions that are often treated by AMS products:
Medicare has a NCD for the Treatment of Impotence (230.4). This NCD states that penile prosthesis is a covered benefit when a patient meets medical necessity.
Medicare has a NCD for the Incontinence Control Devices (230.10). This NCD states that “such a device is covered when its use is reasonable and necessary for the individual patient.”
Does my private insurance cover AMS products?
AMS recommends that you work with your physician's office to verify coverage and benefits prior to the procedure being performed. There are also steps you can take to minimize the chances of an improperly processed or denied claim.
Read your insurance policy. It's better to know what your insurance company will cover before you receive a service. It is also possible that some services may need to be approved by your insurance company before your doctor can provide them.
If you still have questions about your coverage, call your insurance company and ask a representative to explain it.
Remember your insurance company, not your doctor, makes decisions about what will be paid for and what will not.
Does my private insurance cover penile prosthesis?
AMS recommends that your doctor's office send a written letter of predetermination to your private insurance company. This letter should ask if you meet the medical necessity requirements for the procedure, in addition to verifying your individual policy has coverage for this procedure. Insurance companies typically send a written response back informing you if you meet both requirements.
I have been denied a penile prostheses by my insurance. What are my options?
Please review some of options below that you might consider. First determine what type of denial you received.
- Is the denial based on a contract exclusion?
Review your benefit information for specific exclusion language. Some types of contract exclusions include no payment for:
- Sexual dysfunction
- Sexual inadequacy
- Penile prosthesis
- Penile implants
Review your benefit information for specific medical benefits such as:
- Prosthetic devices
- Reconstructive surgery
- Surgery to repair body function
You have the right to appeal any denial from your health plan.
In many cases, there is a time limit following the denial in which your appeal must be received. Check your benefit information or any denial letter you received for specific timelines.
My insurance still won't pay. What can I do?
You have gone through the entire appeal process and your insurance still won't pay. If the contract language has a clearly written exclusion, your insurance may legally continue to deny coverage. What are your remaining options?
Review other medical policies you may have.
- Do you have Medicare?
- Are you covered under a secondary plan by someone else, such as a spouse?
- Have you served in the military and are covered under TriCare?
- Do you qualify under Cobra to be part of another plan?
- Is your health plan a self-funded program? Check with your Human Resource Department to determine whether you are covered under a self-funded program. Employers can make a final determination for coverage in self-funded plans. Request information on the process involved in having your request reviewed for coverage.
Explore the opportunity for open enrollment
- This usually occurs at year-end and may allow you to choose another health plan.
- Determine whether another option is offered that may have benefits for erectile dysfunction and penile prostheses.
- Determine whether you are able to upgrade your current plan by paying extra premiums. (These are referred to as riders.)
Paying for your surgery out-of-pocket may not be the most desirable option, but it may be your only option if you have exhausted all others. Here are considerations that could make self-payment more feasible:
- Negotiate prices.
- Explore all your options regarding where you have your procedure performed. If your health plan is not paying for any of the costs, you may want to research prices at facilities outside of your health plan’s network and negotiate a price you are comfortable with.
- Utilize pre-tax flex spending plans.
- Explore loan options
Talk to a specialist today.
A brighter tomorrow starts with a phone call today. Browse our database to find the right physician and make an appointment. It’s time to talk about what’s possible.
For questions regarding insurance benefits and procedures utilizing AMS products:
AMS Global Market Access
1 (888) 865-3373
Free Medicare assistance is also available through the State Health Insurance Assistance Program (SHIP). Counselors can provide one-on-one help with Medicare questions and problems.
While AMS has made reasonable efforts to ensure the accuracy of the information set forth herein, AMS does not guarantee reimbursement coverage or amounts for any product or procedure nor does AMS recommend any particular product or procedure for any individual patient. The information described herein is provided solely as a guide for AMS products and is based on publicly available information from CMS. It is the responsibility of the provider to report codes that accu¬rately describe the products, procedures, and individual patient’s medical condition(s). Providers should contact the appropriate payers directly if they have questions or need specific information.
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